Please help, I am frightened! (7 y/o Pekingese)

[Lola]

It's not that bad actually, she would still eat the same quantity just not all at once like before. But she eats it nonetheless. I am just telling you all the behavioral changes that I've noticed.
The IMS examined her on Tuesday, she said she looked beautiful:)

[goldengirl88]

Nadia:
The appetite is concerning to me too. So you are giving her 15mg twice a day?
How about if you went to 15 mg in the morning and 10mg at nite. That would knock her totsl down to 25mg. Itnis sounding like she is exhibiting signs of going low and tou do not want that, but still want her controlled. If it were Tipper I would got to 25 as I am not sure the 20 mg will control her enough, but I would be lowering the dose if it were me. Blessings
Patti

[Lola]

I think it's safe to go down to 10mg x2 a day as long as I'm not hurting my baby. If I have to adjust up again in 3 week I will. I don't mind doing ACTH tests every 2-3 weeks as long as I'm not putting her in danger. please let me know what you think.

[Harley PoMMom]

I think it's safe to go down to 10mg x2 a day as long as I'm not hurting my baby. If I have to adjust up again in 3 week I will. I don't mind doing ACTH tests every 2-3 weeks as long as I'm not putting her in danger. please let me know what you think.

I think dropping down to 10 mg twice a day is a really good plan because some dogs have had their cortisol continue to drop while being on the same dose over a period of time.

Keep us posted ;)

Hugs, Lori

[Lola]

Thank you Lori,
That's what I think too, especially that in 60 days her post dropped from 5.6 to 2.7 on the same dose. That's a huge drop!
I will redo the ACTH in 2 weeks, hopefully it will give us some good news.

Nadia

[Lola]

I emailed Dr Bruyette and he thinks that dropping to 10mg 2x a day is a perfect decision.

Nadia

[molly muffin]

I am late to the discussion, but really glad to hear that Lola is doing well, looks good and ALKP is so well. With the appetite decreasing I can see where it makes a lot of sense to drop the vetroyl dosage and see how she does on that.

You're doing awesome to stay so on top of all this.

sharlene and molly muffin

[addy]

then you have a plan!!!:)

I think it makes sense. I went through that with my Zoe.

[Lola]

Thank you all.
I am so grateful to each and everyone of you, it's so hard doing it alone, but this forum has been a tremendous resource.

Nadia

[goldengirl88]

Nadia:
Terrific man that Dr. Bruyette, I am glad he helped you. You are doing a great job with Lola. Crossing my fingers this will be a good dose. Blessings
Patti

[molly muffin]

You are never alone while you have this bunch around. :)

We'll be here cheering you and Lola on, every time.

hugs
Sharlene and molly muffin

[Lola]

I just got Lola's test results. Everything looked good except for the calcium level. It's a td bit out of range (high). What do you think could have caused that to go up? What could be done to lower it? Could it be because of the cream cheese I give her with the pill? I'm sorry if it's a silly question, but I'm panicking again. The doctor said to test again with the next ACTH.
Please let me know what you think.
I will post the numbers when I get home

Nadia

[goldengirl88]

Nadia:
How was her thyroid panel? Tipper had high calcium because she had a slow thyroid . The thyroid meds took care of it. The calcium is regulated by the thyroid. If it only rose a tad I would not worry, but keep an eye on it if it goes up them I would investigate the cause. You can't get rid of us you are stuck with us!! Blessings
Patti

[Lola]

Here's what Dr Bruyette said:

I would not be too concerned. The first thing to do is recheck the calcium in a week or two following a 12 hour case. Let me know what you find.

The IMS said the exact same thing, to recheck again in 2 weeks, but What does "a 12 hour case" mean?

Nadia

[goldengirl88]

Nadia:
I am thinking it means since you discovered it was low about 12 hours ago?? Hope you and Lola have a good weekend. Blessings

Patti

[labblab]

Here's what Dr Bruyette said:

I would not be too concerned. The first thing to do is recheck the calcium in a week or two following a 12 hour case. Let me know what you find.

The IMS said the exact same thing, to recheck again in 2 weeks, but What does "a 12 hour case" mean?

Nadia
Perhaps he meant "a 12 hour fast." Maybe he was dictating his reply and the word got picked up incorrectly. You may want to double-check this with him, though, because you do not want to fast Lola before an ACTH. If this is what he means, the testing will have to be performed at different times.

Marianne

[Lola]

I emailed him again this morning, that's what he said:) a 12 hour fast.
However, I don't know how that would be possible with the Vetoryl that's administered twice a day. I asked him that and I'm waiting for his reply.

Nadia

[goldengirl88]

well that mystery is solved!

[goldengirl88]

Hi Nadia:
How is Lola doing on the new dose? I hope everything is going along just fine. Blessings
Patti

[Lola]

Hi Patti,
Thank you for checking on us. I think this dose is perfect, hopefully the next ACTH will confirm. She's more active and happier overall. Her apetite is back to normal, which is being picky about her food, as opposed to devouring anything that lays around:)
I will follow Dr Bruyette's advise and do a 12 hr fast blood draw for the calcium testing. I have one question thought, should I withhold both food and water for 12 hours, of just food?

Nadia

[goldengirl88]

Nadia:
I would not withold water as you are never to do that with a Cushings dog. I had this done on Tipper and only fasted her, she had water as always. I am glad to hear that Lola is doing well on this dosage. It seems to agree with her. Blessings
Patti

[lulusmom]

You need only withhold food for 12 hours. You withhold food and water for surgical procedures requiring anesthesia.

[goldengirl88]

Nadia:
Tipper is having a procedure next month and they agreed to take her first thing in the morning because of the fasting and no water situation. She usually does not drink a lot in the morning anyway so this will help though. Hope the calcium test comes out fine. Blessings
Patti

[Lola]

I re did the calcium test this morning. The doctor said she wants to test the levels of the "ionized" calcium, if these are out of range then we need to worry about last week's calcium test results, if not then just ignore it.
Today's test came back perfectly within the normal range, so she told me not to worry about it.

Ca++: 1.32 mmol/L-----normal range: 1.25- 1.50


what do you guys think?


thank you

[Trish]

Hi - just had a comment on the high calcium. My dog also had one, they think it was tied in with his albumin level. Our IMS commented on it as below:


"Trish mentions a high albumin reading. As you know there is only one reason for that and that is dehydration. That in turn can then cause the calcium to be slightly elevated. I think the best explanation then is that if he had high albumin and calcium at the same time on a blood test then he was dehydrated at that time for some reason"



Was Lola's albumin OK?

[Trish]

Ahhh see you updated result, I think that is fantastic number!

[goldengirl88]

Nadia:
Great news, so you can have peace of mind now. Hope Lola is still doing well. Blessings
Patti

[Lola]

Here's what Dr Bruyette said:

"If the ionized is normal then all is well"

Nadia

[goldengirl88]

He is a wonderful man.

[goldengirl88]

Nadia:
Don't worry about replying to me, I know you are so busy with your job etc. I post to see how Lola is because I care. I do not work anymore and have more time than you do, so just take care of your girl as I know you are thinking of us. This forum has helped with my girl so much that I do try to give back at lest two hours a day. Blessings
Patti

[addy]

Great news, I hope all is well with you and Lola and continues to be

[Lola]

Hello everyone, I hope you all had a great holiday weekend.
Lola is going for another ACTH Stim test tomorrow, I am keeping my fingers crossed, she seems to be doing well on this lower dose and I hope the results confirm that without any surprises.
I have a question about an unrelated issue, your help and input is greatly appreciated.
We recently moved to a different county, so I went to renew Lola's license and registration at the new County. I found out that as of 7/1/13, they require the animal to be microchiped. I have not microchiped Lola because of all the horror stories I read about reactions, tumors, and even death... now they are saying it's either have a her microchiped within a month or get a letter from the vet explaining why she can't be. I am stressing over this like crazy and don't know what to do. with everything Lola is going through, I don't want to put her through this.
Any advice will be hugely appreciated.


Nadia

[Budsters Mom]

Hi Nadia,

I haven't read any horror stories about microchipping. Maybe I should have researched it? Buddy was microchipped when he was neutered. He was six months old then. I frankly never thought about it much again. It never caused any problems throughout his lifetime.

They recommend doing it when they have some kind of surgery or other procedure where they are under anesthesia. The chip is approximately the size of a grain of rice. It takes a big needle to insert it and it hurts! That's the reason for doing it when they are under anesthesia for something else, if possible.

Rosie was microchipped also. She was done when she was four months old and needed to be under anesthesia to have her ears cleaned out. I microchipped and had her spayed all at the same time.

I hope this helps. Others should be around shortly to share their experiences. Hopefully they will know more than I do.

Kathy

[Lola]

isn't she too old to be microchiped at 8 y/o? is it easier when they're younger?

[molly muffin]

hmm, I don't know of any problems with microchipping either, but I know that rescues will often have dogs microchipped or have the adoptive parents microchip, no matter what the age.

Have you spoken with your vet about getting a letter if you don't want to have it done?

hugs,
Sharlene and molly muffin

[Lola]

I am taking Lola to the vet tomorrow and will discuss this issues with them. I just wanted to ask the members for their advice based on their own personal experiences.


Nadia

[molly muffin]

I haven't heard of any problems, but if any of the others have I am sure they pop in to let you know. You're right, it's always a good idea to check and see. Just because I haven't heard of problems doesn't mean there aren't any of course. :)

Hopefully you're vet will just write a letter and you won't have to worry about it any more.

hugs
Sharlene and molly muffin

[flynnandian]

there is a legal obligation in my country to chip your dog and cat for a long time.
never heared of anything gone wrong, except, when the chip is not placed correctly it can wander to an other place than the neck where it is originally placed.
pedigree dogs are chipped for ages, even 7 week old chi-puppies.
so i will not worry about the consequences.
the needle looks nasty, but even puppies/kittens seldom cry.

[Harley PoMMom]

The only issue I see is that dog's with Cushing's may take longer to heal, I think discussing the microchipping with you vet would be your best bet. My Sampson is chipped also, but this was done before he came to me, haven't had any problems.

Hugs, Lori

[labblab]

My dogs are both chipped and we've never had any problems. They were fine immediately after it was done. I asked to have it done because it gives me great peace of mind that they could be identified and returned to me if we were ever separated -- we do cross-country traveling with them.

Marianne

[Squirt's Mom]

I have heard of the chip migrating from its original site but that is all I've heard and no damage was caused - just panic when they couldn't locate it for a bit! :D

[Lola]

Thank you all for your good advice- I will definitely be discussing this with the vet today, and will let you know what they say.

Nadia

[molly muffin]

Hi Nadia, what did the vet have to say today?

hugs
Sharlene and molly muffin

[Lola]

Hello everyone,

Lola went for her ACTH and BP reading yesterday. BP was 150 yeaaaa!
the IMS jus called me with the ACTH results:
Pre: 2.5
Post: 4.2
she thinks that these are great number and advised to keep the same dose of 10mg x2/day for another 3 months and retest again.

What do you guys think?


Nadia

[molly muffin]

I think these are really good numbers! With Lola doing so well right now with her cortisol, you should be very proud. It hasn't been an easy journey to get there.

Great on the BP too. :)

What did the vet say about the microchipping?

hugs
Sharlene and molly muffin

[Lola]

Thank you Sharlene:)
She said that she doesn't think it's a good idea either to have her microchiped now, with Cushing's she could be prone to infections at the injection site. She is writing a letter for me, hopefully the County will take it and get Lola's license renewed.


Nadia

[Harley PoMMom]

Hello everyone,

Lola went for her ACTH and BP reading yesterday. BP was 150 yeaaaa!
the IMS jus called me with the ACTH results:
Pre: 2.5
Post: 4.2
she thinks that these are great number and advised to keep the same dose of 10mg x2/day for another 3 months and retest again.

What do you guys think?


Nadia

I think those ACTH results are great!! How are Lola's symptoms?

If her symptoms are controlled then retesting in 3 months sounds like a good plan.

You're doing a wonderful job, Nadia!!

Hugs, Lori

[molly muffin]

That is great that she will write the letter. It makes sense that it could be a risk of infection, so hopefully the county will accept it. Can't think why they wouldn 't.

hugs
Sharlene and molly muffin

[addy]

Great news on the stim and as Lori already mentioned, if Lola's symptoms are controlled, don't change her dose, retest in 3 months unless her symptoms change.

[Lola]

I think those ACTH results are great!! How are Lola's symptoms?

If her symptoms are controlled then retesting in 3 months sounds like a good plan.

You're doing a wonderful job, Nadia!!

Hugs, Lori

Lola's symptoms are very well controlled, she's more active and a lot happier now:) I couldn't be happier!

[Harley PoMMom]

Lola's symptoms are very well controlled, she's more active and a lot happier now:) I couldn't be happier!

Yes!!, that is great news, and I couldn't be any happier for you both! ;)

[molly muffin]

Hi, how are things going with Lola?

Hope she is still having great days and lots of fun.

hugs
Sharlene and molly muffin

[Lola]

Hi Sharlene,
You're so sweet, thank you for checking on us. Lola is still doing good, the knee is still acting up. I think I will continue the laser sessions a little longer than expected. It seems that the Cushing's symptoms are somewhat under control for now, the next test is due in October. I will keep you updated.

Nadia

[molly muffin]

Hi Nadia,
It can take a very long time for an ACL injury to heal itself, no jumping, no running on it, etc and that is very hard to do sometimes with them.
I think the laser probably continues to help with that healing, so good to continue that. Anything that makes her feel better right :)
Glad to hear that everything else is going along fine though.

hugs
Sharlene and molly muffin

[Lola]

Hello everyone, I have a little issue I need help with.
Lola started scooting again, her anal glands needed to be expressed. I took her to the vet, got the glands cleaned and gave her a sanitary groom around her back area. She was supposed to stop scooting after that but she continued to so that, 4 days later she is still doing it. I took her back to the vet twice already, 3 times total in 4 days. she said that she doesn't see anything going on with the glands or inside, the area is a little pink from being dragged on the floor, she suggested I give Lola one Zyrtec if really needed, and try to sooth the area with Aloe Vera or something similar. She thinks it could be just the hair recently cut around her anus that making her itch.
I want her to get better fast, she breaks my heart every time she does that because I know it's making her uncomfortable, what can I use to get a faster result?

Thank you

[lulusmom]

My pups always drug their butt on the carpet when they had a close shave around the anus. I've also had them drag their butts due to parasites so be sure to do some poop patrol to check for worms.

[Lola]

Is ani-itch hydrocortisone spray ok to apply on her? I believe it's just an itch caused by the close shave, I just don't know what to apply to relieve the burn.

Thank you

[molly muffin]

You could also try a compress of camomile tea against the area.

Hugs
Sharlene and Molly muffin.

[Lola]

Good morning all,

Lola's urine PH came back high for the first time, it's only one point out of range, at 8. the vet doesn't seem to be too concerned about it. this is the first time that it came back high. is it indicative of something else? what could be done to bring it down?

I should probably mention that the urine sample was taken after the cortrosyn injection (ACTH Stim test), not before like they usually do.

thank you

[Lola]

Hello everyone,
I hope everyone had a great new year. I have been away overseas for a while that's why I haven't been posting anything.
I hope all the Cush pups are improving.

God bless all

[molly muffin]

Great to hear from you.
Happy New Years to you too!
How is Lola doing?

hugs

[Lola]

Lola is doing great. Her last blood work from October came back perfect, ACTH, CBC and thyroid. We just redid all the tests again this week, the only thing we adjusted last time is bringing down the Soloxine a bit because the T4 post pill was off range.
This time around, the ALK went slightly up, from 131 to 161. (Still a huge improvement from the initial 1200 a year ago!), the other value that was high was the triglycerides. I looked at the test history from last year, it seems that it goes up and down constantly, this time it almost doubled at 567 (normal range 29-291), this concerns me a little because I haven't changed anything as far as her diet or fish oil intake. I don't know what else I can do to stabilize the triglycerides??
Her pre and post numbers were respectively 3.3 and 3.4. Her T4 post pill was 1.8.
Any recommendations about the Triglycerides and the ALK?
Other than that Lola is doing great:)


Nadia

[Harley PoMMom]

Hi Nadia,

Thank you so much for coming back and updating us, and I am so happy to hear that Lola is doing well with her treatment...those are great ACTH stim numbers!!!

Even with treatment some dog's ALK numbers never do come back down to within normal ranges, is Lola getting any kind of liver supplementation?

I'd have to do a search on how to bring those Triglycerides levels down, I'll let you know if I find anything.

Hugs, Lori

[Lola]

Thank you so much Lori, you're so sweet.
Of course, the people here were a huge help for me when I started my journey a year ago, and if my experience can help other people, the least I can do is share it! it's just not always easy to find time, with work and life!

Lola's ALK showed steady decrease over the past 12 months, this is the first time that they picked up a few points. She has been on Denamarin once a day for 12 months now. is there any other good liver supplement that I can may be add to that?
I also give her pet's Fish Oil, once a day as well. the Triglycerides on the other hands were up and down with no pattern whatsoever, but the last 2 blood tests they were within normal range, in three months they almost doubled! that's why I am concerned. I was giving her the Vetoryl with a little bit of cream cheese, but I will stop doing that . I just went and bought some chicken breast that I am going to boil, and will use that with the Vetoryl going forward, I hope that wont be a problem as far as medicine absorption.
thank you for looking into the Triglycerides for me, I appreciate it immensely.

Nadia

[Harley PoMMom]

From what I have read you are doing everything that one can do (diet, fish oil) to lower them Triglycerides. There are other health issues that can raise Triglycerides such as hypothyroidism or diabetes.

As for the liver supplements, denamarin is one that the vets do recommend, it does have to given on a empty stomach to be absorbed properly. I've read that Vit E is also a good supplement to give a dog to help the liver. With Harley, I used milk thistle along with Vit E because it was cheaper than the denamarin and it didn't have to given on a empty tummy. One note with milk thistle that I have read is that it is advised to stop it periodically and then restart, as an example: give it for 6 weeks than stop it for 2-3 weeks.

Vetoryl is a fat-soluble drug but I think giving it with the meal is sufficient enough for it to be absorbed properly.

Keep us updated ;)

Hugs, Lori

[Squirt's Mom]

Nadia! So good to hear from you again and especially to hear that our sweet Lola continues to do well! Of course, she has an exceptional mom. ;)

[Lola]

Thank you all for your help, it really means a lot!
I just realized something, maybe the triglycerides going up have something to do with adjusting the Soloxin down over the past 3 months.
in October, her T4 Post Pill was 6.4 HIGH (normal range 2.5-6.0), so the IMS adjusted the Soloxin from 0.15mg 2xday down to 0.1mg 2xday. we tested again last week and T4 was 1.8, which is very low. the IMS didn't' make any adjustments to the Soloxin this time around. should I call her back and revisit this? I am starting to think that the low thyroid have something to do with the increased triglycerides, what do you think?


Nadia

[Harley PoMMom]

should I call her back and revisit this? I am starting to think that the low thyroid have something to do with the increased triglycerides, what do you think?
Nadia

Yes, I think I would, and oh, another thing :eek::) now this is just me but if I am having a thyroid panel performed I would send it to Dr Dodds as she is considered an expert in canine thyroid issues. Here's an excerpt from her website:
Hemolife is dedicated to providing the highest quality laboratory diagnostic work and expert interpretation of data. This service is available to veterinarians worldwide and to individual animal owners through their veterinarian. Hemolife is unique in routinely offering expert clinical interpretive diagnostic comments that take into account the age, sex, and breed type, and activity of the animal; this yields an expected normal reference range for an individual pet (termed the “Case Specific” range on our reports) that differs from the generic broad reference range for the species (termed “General Range” on our reports). Hemolife has participated in the regular Endocrinology Proficiency Testing from the Veterinary Laboratory Association Quality Assurance Program (VLA-QAP) since 2008.

She takes everything in consideration, such as the breed, sex, and even if the dog is being treated for any type of illness such as Cushing's. According to her there are specific drugs that might influence thyroid function (e.g. corticosteroids, phenobarbital, potentiated sulfonamides, dietary soy and soy phytoestrogens, insulin, narcotic analgesics, salicylates, tricyclic antidepressants, furosemide, phenylbutazone, and o, p1-DDD which is Lysodren ).

Link to her website: http://www.hemopet.org/veterinary-diagnostic-laboratory.html

[Lola]

I emailed Dr Bruyette with same concern and here's what he said:

I think those tests all look good and I would not make any changes. Lets see what things look like at the next recheck.

Dave


What do you think?

[Harley PoMMom]

I hold Dr Bruyette in high regard so if he thinks that waiting until a recheck is best, well, that's good enough for me! ;) Please do let us know how it goes, ok?

Kudos to you for emailing him, You are doing such an excellent job with Lola!!

Hugs, Lori

[Lola]

Thank you Lori:) I am trying:)

I will call the IMS on Monday anyway and let her know my concern.

I think it would be wise to wait one month only and retest the T4 and Triglycerides alone just to be on the safe side. I am such a paranoid mom, I know I am going to drive myself insane otherwise:)


Nadia

[Lola]

I have been thinking of getting a second IMS opinion on Lola's overall condition/treatment. Can anyone recommend a good IMS in the Orange County/riverside county area in Southern California?

Any recommendations are very much appreciated,


Nadia

[Harley PoMMom]

I found this post to a member from one of Administrators, Glynda. Right now, for personal reasons, Glynda is not actively posting so I hope that one of her recommendations will work out for you.



It sounds like you are in Southern California so I have no problem recommending excellent specialists in Los Angeles and Orange County. If you are in Orange County, I highly recommend that you consider VCA All Care Referral Center in Fountain Valley. I live in Rancho Cucamonga and don't mind the hour to hour and half drive there. My dogs treat with the Director of Internal Medicine, Dr. Michael Moore. If you are closer to L.A., I highly recommend Dr. David Bruyette, Medical Director at VCA West Los Angeles Animal Hospital. Both of these specialists are excellent and I don't know if you have noticed but we have a video of Dr. Bruyette discussing Trilostane in our Resources Forum.

VCA All Care Referral
http://www.acarc.com/

VCA West Los Angeles
http://www.vcawla.com/

Glynda

Hugs, Lori

[Lola]

Thank you so much Lori, I have considered making an appointment with Dr Bruyette but was leaving it as a last resort.

Nadia

[Lola]

I was reading the thread from a couple of years ago where Dr Bruyette was answering members' questions. I came across the following post:

This is what I recommend and there are geographical/personal issues with regards to what drugs to use in dogs with PDH.

1) For dogs with mild symptoms or for owners where cost is an issue we start with Anipryl for 2 months. If that fails to resolve the symptoms we move on to another drug.
2) For dogs that failed Anipryl initially or that have moderate to severe symptoms and we dont want to wait 2 months to see improvement we use trilostane.
3) We only use op-DDD when everything else fails. We and others have approached the FDA in the past about getting op-DDD approved in the dog and there is about zero chance of that happening. Too many side-effects and manufacturing isssues and the drug will probably come off market soon in the US since very few people take the drug.
4) Any adrenolytic agent or enzyme blocker can raise steroid intermediates to some degree. Whether this is an issue clinically depends on the given dog, the dose of medication used, the duration of treatment and concurrent diseases and/or medications.
5) Any drug that lowers cortisol levels below normal will raise ACTH levels. In man, this has been shown to accelerate pituitary tumor growth (Nelsons syndrome). Not clear this is an issue in dogs as we see large tumors at the time of initial diagnosis and in dogs on long term therapy.
6) We recommend that all dogs have a MRI when they are diagnosed with PDH and at anytime they develop a decreased appetite, increased thirst and behavior changes.
7) In general adrenal tumors are best treated with surgery as medical treatment is palliative only.

Dave Bruyette DVM DACVIM

Item 6 caught my attention, should I have had an MRI done a year ago?
What dou you guys think about the necessity of the MRI in early diagnostic stages?


Nadia

[labblab]

Dr. Bruyette is not the only clinician/researcher who has recommended imaging of the head for every dog who is suspected of suffering from pituitary Cushing's. The rationale for this is that pituitary tumors that are already large at the time of diagnosis may be more successfully treated (radiation, surgery) if they are identified before they have advanced far enough to cause neurological symptoms. And in a perfect world where expense was no issue to owners, universal screening for larger tumors might be a good idea.

For an owner who would have the financial means and ability to pursue treatment for a macroadenoma (either radiation or surgery), then a screening image could be very helpful. But the imaging alone is quite expensive and for many folks, simply finding the money for the basic diagnostic tests and medication is such a stretch in and of itself. And if the pet parent feels as though they would not wish to pursue prolonged or extremely expensive treatment for their dog even in the event that a macrotumor is identified, then imaging may not be serving any useful purpose unless the dog develops symptoms that make a macrotumor seem likely and the owners later simply decide they want confirmation of the problem.

We ended up euthanizing our own Cushpup because he developed severe neurological problems consistent with an expanding pituitary tumor. However, for several reasons, we did not obtain confirmation through imaging ourselves. Probably the primary reason was because we knew that even if the macrotumor was identified, we would not have chosen to put him through the lengthy conventional radiation therapy that was the norm at the time. But all these decisions regarding screening and treatment are individual ones that will vary from parent to parent.

As a sidebar note, I don't want any of our Lysodren users to be freaked out by Dr. Bruyette's comments under #3. I have enormous respect for him, but I recognize that his disfavor for Lysodren is offset by other respected clinicians who prefer Lysodren as their primary treatment choice for PDH. Also, his warnings about Lysodren being removed from the market have never come to pass and we have no reason to believe that will change now.

Marianne

[Lola]

Thank you Marianne for your input and for sharing your own experience. You know how hard it is to want to make sure we are doing everything possible to make our babies lives better!
Also, I believe that Dr Bruyette was talking about op-DDD in item 3, that may or may not be removed from the market, not lysodren. There's a lot of literature and resources in this forum, which is a huge help. I m still trying to make sense of it all.


Nadia

[labblab]

Hi again, Nadia. Lysodren, mitotane, and op-DDD are all the same active chemical. So Dr. Bruyette truly is talking about Lysodren in #3, and we have seen him talk about these related market issues elsewhere. Lysodren is just not often referred to in this way here. ;)


Mitotane is a prescription drug and can only be obtained from a veterinarian or by prescription from a veterinarian.
This drug is not approved for use in animals by the Food and Drug Administration but it is prescribed legally by veterinarians as an extra-label drug.

This drug is registered for use in humans only.
Human formulations: Lysodren® (Bristol-Myers); also called o'p'DDD.
Veterinary formulations: None

And you are very welcome for any thoughts I was able to share!

Marianne

[Lola]

Thank you Marianne for clearing it out for me :) like I said, I am still trying to make sense of all this. I went to school to become an engineer, had I known all this would be waiting for me I would have chosen a different major :)

Nadia

[Lola]

Hello everyone,
I had a question for the forum if any one could answer that would be very much appreciated.

Lola has her ACTH test this Thursday. She just had a small cyst in her front paw that burst this morning. Her vet prescribed Muricin ointment and clavamox antibiotic. She has used both in the past without any side effect, I'm only concerned now because I'm afraid the meds will skew the blood work results and the ACTH stim test.
Thanks for your help

[Harley PoMMom]

The stim test will not be skewed as long as steroids are not listed in the ingredients of those medications.

[budindian]

Welcome from me to even tho I am still very new. Listen to the people here, I wish I had found this forum before I started treatment it would have saved me from a near nervous break down. My vet recommended to high a dose of the trilostane and my baby had a very bad reaction, I thought I was going to loose him during the night, now when I visit the vet I am armed with good information and I am going to start my baby at the lowest possible dose and work up if needed.

[molly muffin]

Lori is right antibiotic ointment should be just fine.

[Lola]

Hi all,
can someone please recommend a really good IMS in the Orange County, CA area? I am looking to replace the one I go to right now.
I am sorry for the short posts, I just have a lot to figure out right now. I will post more about Lola's progress very soon.

Thank you and god bless you all

[molly muffin]

I really don't know of any personally that haven't been mentioned already I think a search of small animal internal specialist Orange County might help you as there appears to be several. Once you have picked out a couple then do a search for reviews.
I do hope everything is okay with you and Lola. How is her foot?

[Lola]

Thank you Sharlene.
Lola is doing OK I guess, as far as her chushing's. The latest ACTH results weren't very impressive (high), and adjustment of the dose is expected. But that's not my priority right now, she tore her second ACL this morning and I have to get the surgery done this time. I had her seen by a neuro just to rule out any spine injuries, all was good there. I have an appointment with the orthopedic surgeon this coming Tuesday.
I emailed Dr Bruyette and he said that he doesn't see any reasons why I shouldn't go for surgery, and said to keep the vetoryl at same dose (latest pre and post are respectively 5.8 an 7.7). it's actually a good thing to have the cortisol at a high level before surgery, in case that's what the orthopedic surgeon recommends. I will deal with the Vetoryl adjustment after surgery. the triglycerides went down slightly from 567 to 369 (normal range 29-291), but the calcium is high again, 11.9 (normal range 8.9- 11.4). her urine RBC was high at 4-10 (normal range 0-3), and there is trace of protein in her urine.
the reason I am thinking of switching IMS is because this one is so hard to get a hold of, even for refills. and I found out today that they keep hiking their prices for no reason. I never asked about any costs but when I accidentally compared two invoices that were a few months apart, for same services provided, I found out that some of the charges are funky. long story short, I think it's best if I get Lola looked at by a fresh set of eyes.

Nadia

[molly muffin]

That makes perfect sense Nadia as to why you are considering a switch.
Oh no. Another ACL tear. :(.
I have heard that about the cortisol being a bit higher before surgery so they handle it better.
I would monitor the blood values and see if there is anything trending upwards. Calcium seems to be one that can fluctuate as we have been a tad high then back within range.
Does she have crystals in urine or stones anywhere that would cause rbc in urine to be high? What about a UTI?
So many possibilities that have to be ruled out when there are changes

[Squirt's Mom]

Oh dear, so sorry all this came about at one time. It's hard enough finding a new vet when all is stable. I hope the tear is easily repaired an our Lola is up and at 'em soon after! Let us know how things are progressing and best of luck in finding the perfect IMS for her. Squirt and I were so very lucky in our vets.

[Lola]

Hello everyone,

I just came home from taking Lola to 1 neurosurgeon and 2 orthopedic surgeons. The neurosurgeon ruled out any spine injuries, so that was good news, and both orthopedic surgeons recommended conservative management for the ACL tear, the second one said that it seems to already have started to heal, so that's another good news. I will go that route and do some physical and cold laser therapy like I did with the first one. no surgery at this time.

The bad news came from the IMS, she recommends that I increase the Vetoryl to 20mg in the morning and 10mg at night (from 10mg 2x a day). The latest ACTH pre and post were 5.8 and 7.7, Dr Bruyette had recommended that I keep the dose at same so that's why I am a little concerned about such a substantial increase. the other bad news is that she also recommends that we run a malignancy profile because of the high calcium level (11.9 (normal range 8.9- 11.4). That has me a little concerned. What would that uncover and is it really necessary?

Nadia

[molly muffin]

Yes 10 mg seems like a large increase to come down a couple points post. What about adding in a 5 mg of compounded trilostane and see how she does on that?

So sounds like she wants to check the ionized calcium because of the over all calcium being increased. My IMS checked that regularly for a bit and her ionized was high. But of subsequent checks it was not high. So we aren't monitor paring it any more. Ionized calcium is a part of the over all calcium total but is a pointer for parathyroid tumor and some cancers. My gutless is to rule that out. And then the in teased calcium would be due to something else if the ionized is within normal range. I was on pins and needles for at least a month while we where monitoring.

[Lola]

I wrote Dr Bruyette asking for advice, here's what he said:

"
I think if her clinical signs are controlled there is not real reason to raise the dose.

I would repeat the calcium after a 12 hour fast. If its still high then run a PTH and ionized Ca.

Dave
"
This is not the first time that her Ca is high. About a year ago, it came back at 12.1, we then did an ionized Ca test that came back perfectly within range. Two subsequent blood works were done, and both times the Ca was within normal range. So I don't think it's not trending up, it's just not stable.
I will follow Dr Bruyette's advice and see what the results are, hopefully we won't have to do the PTH. Fingers crossed.

Nadia

[Harley PoMMom]

I'll take care of that double post for ya, it happens to me sometimes too! (Looks like Marianne beat me to it!)

I completely agree with Dr. Bruyette in not raising her dose, dose adjustments should never be solely based on ACTH stim numbers.

Hugs, Lori

Is the phosphorus elevated?

[Lola]

Thank you Lori.

No, phosphorus is not high, it's 4.1- Normal range: 2.5- 6.0


Nadia

[molly muffin]

Hi Nadia, that is what we found too, that Molly's calcium is sometimes elevated but not consistently, so that is good and it's good that you Know that happens with her.

Glad Dr. B answered so promptly, if she has no problems, then she Is within range up the the 9.0ug on her post. Some IMS just really like that below 5.0ug.

[Harley PoMMom]

You commonly see high levels of calcium along with phosphorus when there are problems with the parathyroid glands.

[Lola]

Hello everyone,

I did the calcium tests that Dr. Bruyette recommended and just received the results back this morning.

Ionized Calcium: 1.51 (normal range 1.25- 1.45)

Parathyroid Hormone: 1.00 (normal range 0.50- 5.80)

The doctor said that these results are good news because the PTH is within normal range, and that if it was elevated or low then we will suspect either a hyperparathyroidism or malignancy if PTH low.

What do you think?

Are there any other tests that you would recommend at this stage or just wait and redo the tests again in a few months?

Here's the endocrinology interpretation that was written on the test results:

"The elevation of ionized calcium is modest and of questionable significance with regards to the presence of a pathologic hypercalcemia. Therefore one possibility is that these results are fairly normal for this dog. If this dog has pathologic hypercalcemia, this would be the interpretation:
The parathyroid hormone (PTH) result is equivocal. If the concentration of PTH was higher, there would be more confidence in support for a diagnosis of primary hyperparathyroidism. Conversely, I expect to see a lower concentration of PTH with hypercalcemia of malignancy or other causes of parathyroid-independent hypercalcemia. Primary hyperparathyroidism remains as a differential diagnosis."

[molly muffin]

You did say that the ionized could be her normal. So with the parathyroid being I range I wouldn't worry about that. Just monitor and see how things go. We aren't even really monitoring. Ow that we know Molly is good on that front.

[Lola]

I found a little bit of blood this morning at the tip of Lola's poop, towards the end. I called the vet and she said to monitor her next couple stools and see if there's more blood. The anus is clean and no traces of blood. The blood in the stool was red, not dark.
What could have caused that?

Thank you

[Harley PoMMom]

Bright red blood isn't as concerning as the black tarry type, so that is good, now, the blood could be gastro (lower intestines) related or if she had a hard bowel movement and was straining it could be hemorrhoids. Let us know how she is doing.

Hugs, Lori

[Lola]

Thank you Lori,
That's exactly what the vet said. She said to add more fiber to her food and make sure she drinks a lot of water and watch her bowel movement for the next couple of days. Lola didn't seem to be in any distress while pooping, or even after. She was playing and rolling on the carpet like she always does after our walk.
I will let you know how tonight's poop looks :)

Nadia

[molly muffin]

How as her poop last night?

[Lola]

It had a little bit of blood, less than the morning. It was actually some mucus mixed with blood, it's on the tip of the stool that first comes out. That was it, no blood anywhere else. I even clean her anus with a wet wipe afterwards, it's perfectly clean and no traces of blood.
Same thing again this morning, noticeably less and less blood/mucus, comes out first then normal poop afterward.
I don't know how to interpret this. Is there anything I should be doing to remedy this?


thank you

[Lola]

I should probably mention that Lola just finished a course of Metacam liquid for her knee injury.
Could the blood in the stool be caused by the Metacam? If so, will that need medical attention or will it heal on its own one that she's not taking the Metacam any longer?

Thank you

[Harley PoMMom]

Bloody stools are listed as a side effect of Metacam (also known as Meloxicam). I found an article, although it is geared for humans, stating that an acid reducing medication should be taken when Metacam is being used for pain:
In general, since most NSAIDs inhibit production of the enzyme that helps protect the stomach and intestinal lining from being damaged by stomach acid, reducing stomach acid is a good thing for those taking NSAIDs. Medicines that control or decrease acid in the stomach are considered a valuable palliative; if taken regularly while NSAIDs are used, they offer some protection to those who must take NSAIDs.

Here's a link to the article: http://s3.gi.org/patients/pdfs/ulcerprotect.pdf

Tramadol may be a better option with our cushdogs.

Hugs, Lori

[Lola]

Hello everyone,

Lola has been having some issues lately. she has been having loose stools for a few days now. I am thinking it's because of the sweet potato/cod fish based food that she has been on, I may be wrong though. I took her to the vet on Thursday, she prescribed Metronidazole and probiotics, I also switched her to a bland diet of steamed rice and chicken since last night. Her poop is still pretty loose, she doesn't need to go often but when she goes it's very loose. She refused to go to the bathroom last night so I thought maybe the rice was making her constipated, but when she went again this morning, she still had loos stool :(
I had another ACTH stim test done yesterday because we were due for a Vetoryl dose adjustment a month ago, which I postponed because of the calcium issues. So I redid the stim test to have a baseline for the next adjustment. I should have the numbers back this morning, I will post them as soon as I get them from the vet.
I am still giving her the Metronidazole liquid as prescribed. I should mention that other than the loose stool, she doesn't have any other symptoms: no vomiting or nausea, her appetite is pretty good and she's still very playful (when her cortisol is not spiking).
Anything you can suggest is welcome, I am at the end of my rope here and I don't know what else I can do to stop the loose stool:( I tried the best and most expensive foods out there, nothing worked. What do you guys feed your cush pups?

Nadia

[molly muffin]

I add in a bit of Fromms weight management food to give Molly enough fiber to not have loose stools. If I don't do that then she will for sure and we will be doing the poopy bum wipes.

[Squirt's Mom]

Sharlene, that is funny! :p

[molly muffin]

Gawd save me from my iPad typing errors. Fixed so it looks like real words.

[Lola]

How soon should the Metrodinazole start working? She is been taking it for 2 days and poop is still the same.
I'm thinking to put her back on the Wellness Core kibble, she has done well on it for a couple of years. What do you think?

[Trish]

Hey Song, Flynn gets this problem periodically. I give him a single protein, currently venison Ziwipeak. It is grain free which I think helps him tremendously. I also give him Metamucil powder, half teaspoon dissolved in about 50ml water on his evening meal for extra fibre as recommended by his IMS. He had a really loose poop last night on our walk, icky and not nice wiping it off the footpath! But I have metronidazole on hand so gave it last night and this morning to hopefully nip it in the bud. His gut is bad with chicken so we avoid that even though it is his favourite thing!

[Lola]

Thank you Trish. I will keep her on the chicken and white rice for a day or two and see if that helps, along with the metronidazole. I think it's a good idea to put her back on the grain free low fat kibble, she did very well on it until I switched back to whole, home cooked sweet potato and cod fish back in January.
I will update you all on her poop tonight:)


Nadia

[molly muffin]

Hoping last nights poop was a bit more solid. Sometimes it takes a week on the medication. My vet gave a high dose for. 3 days the last time this happened with Molly.

[Lola]

Lola is not feeling well. she is very reluctant to go to the bathroom, I have to take her outside several times for her to finally poop. I initially thought she was constipated from the Metronidazole and the rice, but when she goes it's still very soft. I am thinking her knees and hips are hurting her and she is reluctant to squat. It breaks my heart to see her like that. I don't know what else I can do to make her feel better. She looks miserable at home, very lethargic and not wanting to play or interact in any way. She used to follow me everywhere around the house, now she just sits on one spot and stares ahead.
I have so may decisions I have to make concurrently that my head is spinning, I don't want to subject her to so many changes at once so I am trying t prioritize. I need to find a new IMS, change her food, tweak the Vetoryl dose and redo the ACTH in two weeks, all this while keeping her mobility as restricted as possible because of both torn ACLs. What do you think I should focus on first?
Any advice or input is very much appreciated


Nadia

[Lola]

I received THE call from the vet this morning about Lola's latest Stim test results.

What can I say, they are not the results I was expecting. the pre and post were both normal: Pre 1.5 and Post 4.7. This is even more confusing because now I can't blame her lethargy and panting at night on the cortisol, what is it then? I also am even more concerned because exactly a month ago when we had the last Stim test, her pre and Post were 5.8 and 7.7 respectively. The IMS had recommended then that I raise the dose but I chose not to. this is a huge drop on the same dose, and this makes me even more concerned.

Lola's poop is still very loose, and she doesn't go as often as she's used to. She's not responding well to the Metronidazole so the vet is adding the Tylan. We both believe that this is caused by the Metacam that she has been on recently.

I made an appointment with another IMS tomorrow morning to evaluate Lola and all the new information, hopefully I will get some direction.


Nadia

[Harley PoMMom]

I get a bit concerned when the pre # goes lower than 2 ug/dl, although her post # is great. How was she feeling when her pre and post were 5.8 and 7.7 and how were her symptoms? If she seemed to be doing better with a higher pre/post than maybe Lola is one of them pups who needs her ACTH stim numbers to run a bit higher.

Hope Lola is feeling better soon, keep us posted, ok?

Hugs, Lori

[Lola]

You are right Lori, I think Lola was doing good when her Pre and Post were high, that's why I'm a little concerned. She is showing some lethargy and lack of spunk but I can't tell if that's from the diarrhea or from the low cortisol, I was even thinking that her cortisol was trending up that's why she was lethargic.

What concerns me the most is how low the pre went down in just a moth with the same dose, That I can't explain.

I don't know what to do anymore, should I lower the dose, or keep it the same?


thank you

[labblab]

Nadia, are you still in email contact with Dr. Bruyette? If so, I'd ask his opinion re: these ACTH results, given Lola's current behavior. Just so you'll know, "pre" values can vary significantly from hour to hour, day to day, and testing to testing, even for dogs without Cushing's. For instance, the "pre" value can be greatly affected just by how stressed the dog is on any given day, at the particular time that the blood is drawn. This is why trilostane dosing increases cannot be based on "pre" values alone.

As long as Lola was behaving normally, I don't think a "pre" value of 1.5 would be a great concern in conjunction with a "post" value of 4.7. If the "post" were as low as 1.5 as well, I think it would be a different story.

But Lola does not seem to be behaving normally right now, and the decrease in the "post" value from 7.7 to the 4.7 may be more meaningful. If I were you, I would ask Dr. Bruyette's opinion about the test result and the trilo dose.

Marianne

[Lola]

Thank you Marianne,
I emailed Dr Bruyette a little while ago. I will let you know what he says as soon I get his response.

Nadia

[labblab]

Just wanted to add that I think it's important that he know about the metacam, too. I agree with you and your vet that the metacam, rather than her cortisol level, may have brought on these GI issues.

Marianne

[molly muffin]

Hi Nadia, Did you ever hear anything back from Dr. Bruyette?

wonder what he though about the way she is acting too.

I tend to suspect the metacam also, as it can cause GI upset.

[Lola]

Thank you Sharlene for checking on us.
Dr Bruyette's said that the ACTH numbers were fine, to keep the dose at same until cortisol is checked again. He also said that the GI issues are not related to her cortisol level and are most likely caused by the Metacam.
I took Lola to the IMS on Tuesday. She did a bunch of blood and fecal tests, we also did an abdominal ultrasound. The fecal tests were all negative, no parasites or bacteria. All she saw on the ultrasound was an inflammation on the duodenum and intestin walls, she also showed a mild pancreatitis, no masses or tumors. The adrenals were a little swollen but she said its a normal reaction to prolonged Vetoryl use. She sent her home with sucralfate and Pepcid AC.
Lola is doing better as far as her diarrhea, there's still some darkening in her stool. Could that be caused by the sucralfate? I'm still giving her the Tylan as well. She's still a little groggy and lethargic, but I exoect that if she has tummy issues.


Nadia

[molly muffin]

Hmm, could be the reason, sucralfate is I thought normally used to treat ulcers, mouth, stomach ,intestine, etc in dogs and cats.

If she has a touch of pancreatis then definitely do the small meals several times a day, it is easier on their digestive system, also something easy like the chicken and mushy rice. I always added a probiotic to that too. Not that Molly had pancreatis, but she does occasionally get diarrhea and GI upset.

I imagine that Lola is going to be just fine, having a bump in the road it sounds like but nothing that she can bounce back from in a bit.

[Lola]

Thank you Sharlene, you're very sweet.
I did stop the sucralfate today, she seems better as far as drowsiness. I have been feeding her chicken, rice and probiotics for a few days now.
Hopefully this scary episode will be over soon.


Nadia

[Lola]

Hello everyone,
I haven't been her in a while. I was dealing with some personal issues, sold my house, moved, changed jobs... I don't even know where to start.
Lola has been doing good overall considering everything that's going on. We tested back in July and all the numbers were alright. Here are the numbers from July:

July

ACTH pre 2.0 post 4.8
T4 3.7 (normal 1.0-4.0)

The only other values that were out of range are:

ALP 209 (normal 5-160)
AST 11 (normal 18-121)

All the electrolytes, calcium and everything else was perfectly within range so we didn't make any dose changes. The vetoryl was kept at 10mg twice daily, and the soloxin at 0.1mg twice a day.

We tested again yesterday and several values were out of range. The cortisol was too low.

Here are the values from yesterday's test:

November

ACTH pre 1.5 post 1.5
T4 2.8 (normal 1.0-4.0)
ALP 182 (normal 5-160)
TCO2 Bicarbonate 9 (normal 12-27)
Chloride 106 (normal 108-119)
Triglycerides 436 (normal 20-150)
Anion Gap 32 (normal 11-26)

several other values have become borderline, either high or low, but are still within range.

My vet thinks that the low chloride has something to do with the low cortisol and that Lola may be becoming Adesonian. She is suggesting to cut the vetoryl from 10mg twice daily, to 10mg once daily and test again in a couple of weeks.
The really strange thing is that Lola has never felt better as far as her behavior and activity level. She has been very perky, eats and sleeps well, even goes for longer walks it seems like. So when I see the low cortisol level I am a little perplexed.

I have no idea what the other values I posted mean, other than the triglycerides, which I think can be lowered by giving a good quality fish oil. What do you think about Lola's blood work and low pre and post, should I follow the doctor's advice and lower the dose by half to 10mg once a day from 10mg2xday, or should I stop the Vetoryl altogether until the electrolytes are back to normal. What would you do if you were in my shoes?

As always, I am so thankful for this forum that words cannot express it.

Nadia

[Harley PoMMom]

So glad to hear that Lola is doing so well!! And so sorry to hear that you have been going through some tough times. :(

Those November ACTH stimulation results (pre ~ 1.5 ug/dl and post~ 1.5 ug/dl) are too low for my comfort, so I would definitely decrease her Vetoryl dose. Since she is not showing symptoms of cortisol dropping too low, if this were me, I would start giving her the lower dose strength, the 10 mg once a day, and keep an eye on her for any adverse effects. I would have another ACTH stimulation test performed in 2 weeks or sooner if she starts exhibiting adverse signs.

The Chloride, TCO2 Bicarbonate are part of what makes up the Anion Gap. The Anion Gap result gives clues about the acid/alkaline of the blood.

Hugs, Lori

[labblab]

ACTH pre 1.5 post 1.5
T4 2.8 (normal 1.0-4.0)
ALP 182 (normal 5-160)
TCO2 Bicarbonate 9 (normal 12-27)
Chloride 106 (normal 108-119)
Triglycerides 436 (normal 20-150)
Anion Gap 32 (normal 11-26)

Hi Nadia! It's so good to have you and Lola back with us, although I'm sorry there's any cause to worry. On the "plus" side, Nadia's ALP is lower than previously, so that's good. And her thyroid marker (T4) is right in the middle of the normal range. On the negative side, elevated triglycerides can indeed cause problems, and I really don't know how much significance to give to the abnormalities in the TC02 Bicarbonate, Chloride and Anion Gap.

I have to agree that the ACTH results are right at the basement of the acceptable therapeutic range and do not show any response to stimulation at all. So I understand why your vet is wanting to decrease the Vetoryl so as to allow Lola's adrenal function to rebound somewhat. I think it's great that she's feeling so well, but with those ACTH results, I'd worry that she could quickly and easily slip into symptoms of worrisome oversuppression.

Rather than cutting her Vetoryl dose fully by half, one option might be to switch her to 5 mg. Vetoryl capsules for her evening dosing. Dechra has only recently introduced the 5 mg. capsules, and many vets are not aware they're available. But they are, and that might be a compromise solution that would allow her cortisol to rise a bit, but not by more than you'd wish. Just a thought you might discuss further with your vet.

Marianne

[Lola]

Thank you s much for your advice.
I didn't know about the 5mg either. That's great news.
I think I will feel more comfortable (and not loose my sanity :) ) if I do 10 mg once a day for 2 weeks and retest. I look at her entire ACTH history since this whole thing began 2 years ago, the post has never dropped below 2, so I think at 1.5 it's better to do 10mg. if the cortisol goes up too much then I think we may do the 10mg in the morning and 5mg in the evening, since now we have that option.
I will also recheck the electrolytes in 2 weeks to make sure they are recovering as well.

What do you think?

Nadia

[labblab]

I think that sounds like a very good plan! Please do keep us updated.

Marianne

[Squirt's Mom]

Personally, with those ACTH numbers, I would not feel at all comfortable just lowering the dose. I would want the med STOPPED for a day or so then do another ACTH so I *knew* where the cortisol was. By continuing to give the Vetoryl she may crash. It just isn't worth the risk to me. ;)

[Lola]

I'm really in a difficult position right now and torn what to do, I want to make the best decision for her.
I emailed Dr Bruyette but he hasn't replied yet.
I did some research online and found this document from IDEXX laboratories giving guidelines on how to interpret results based on what treatment is being administered, and in Lola's case, their suggestion is consistent with what Sqiurt's mom is suggesting: stop for a few days and retest, then start at a lower dose.
https://www.idexx.com/resource-library/smallanimal/snap-cortisol-testing-guide-en.pdf

[labblab]

That is certainly the more conservative thing to do, and there's nothing wrong with going that route if that gives you greater peace of mind. The thing is, Lola falls right in the middle of the monitoring treatment recommendations. IDEXX uses a cut-off of 1.5 for their decision-making; Dechra uses a cut-off of 1.45. According to Dechra's charts, if a post-ACTH is lower than 1.45 (or 1.5 per IDEXX) but a dog is doing well clinically, then stop the treatment entirely for a week and then just restart at a lower dose with retesting again after two weeks. If the post-ACTH is greater than 1.45 (or 1.5 per IDEXX), then continue at the same dose. Here's Dechra's newest guidelines:

http://www.dechra-us.com/Files/dechraUSA/downloads/Client%20Literature/Treatment%20and%20Monitoring%20of%20Hyperadrenocor ticism.pdf

So here's Lola, right at the borderline. Which direction do you go? I definitely don't think you'd want to go forward without lowering her dose, especially since there is no rise at all between her pre-ACTH and post-ACTH readings. But my own thinking was that since she is outwardly looking the best that she ever has right now, I'd be fine with your vet's recommendation to lower her dose and retest again in a couple of weeks (assuming she continues to behave normally). But I will certainly defer to Dr. Bruyette's expertise if he thinks otherwise. And as I say, if it brings you more peace of mind yourself, you can certainly stop the dosing altogether for a couple of days (or until you hear back from Dr. Bruyette).

[Renee]

Just wanted to jump in and say that when my pug had similar stim results, we stopped her dosing altogether for 2 weeks, then restarted at a lower dose. My vet confirmed this with Dr Bruyette (I think, or maybe Edwards?). I'd have to look back at my thread to see who she talked to, but she definitely did talk to one of them.

Anyway, no harm in stopping altogether and allowing a little bit of rebound before starting back up at a lower dose. Your girl won't spiral out of control in a few short weeks or just a week if you want to shorten the time frame.

[Lola]

Dr Bruyette just responded to my email and he's suggesting that it's safe to lower the dose to once a day 10mg and retest again in 2 months.
I am confused right now, because in one of his blogs from 2014 he suggested that the Vetoryl should be stopped for a few days and retest again before restarting treatment at 50% lower dose.
I don't know what to do anymore

[Lola]

I went ahead and followed Dr Bruyette's advice. I gave Lola her 10mg/day, but will retest again in a week.
I'm really hoping I'm making the right decision here

[labblab]

Did he say to retest in two months or two weeks? I'm hoping he didn't say to wait two full months....

You may be thinking of Dr. Mark Peterson instead of Dr. Bruyette. Dr. Peterson does have a blog, and I think he is more conservative than Dechra -- he doesn't even like to see a dog's post-ACTH drop below 2.0 when the dog is being treated with trilostane. So as you can see, there are various opinions.

I hate for you to stress yourself out over this decision though, because really, if you want to stop the trilo altogether for a week or so before starting the reduced dose and then retesting, I agree with Renee that it shouldn't be a big deal. Just be sure to tell your vet so that he'll know what you are doing and why.

Marianne

[Squirt's Mom]

You know her best. Keep a close eye on her the next few days and if you see *any* sign the cortisol has continued to drop, stop immediately and call the vet asap. I know she is in the best of hands with her mom, tho. ;)

[labblab]

We were typing at the same time. ;)

Since you monitor Lola so closely, I'm confident you two will do fine. If you have any doubts or concerns about how she's behaving, just go ahead and hold the drug. And if she's still doing great a week from now, you may want to hold off with the next testing until that 10-14 day mark so that you have a more accurate assessment of the true effect of this dosing change.

[Lola]

Thank you all for you concern and your priceless advice.
Dr Bruyette's did say 2 months but I'm hoping it's just a typo. In one of his web Q and A, he recommends to stop the dose of the post is below 1.45, not 1.5. I believe that's why he didn't suggest that in Lola's case, especially when she's clinicaly fine.
I will continue with the lower dose and will definitely be testing again in one week, ACTH and blood chemistry including electrolytes. I won't take any chances :) and of course I will be watching her like a hawk in the meantime :)

Nadia

[Lola]

I emailed Dr Bruyette again asking for clarification about the 2 months testing. He confirmed what he had initially recommended, he said to test again on 2 months and also said that the electrolytes are not related to Addisons!
I am really confused now.

here's his email:

I would retest in 2 months. I dont think the electrolytes are related to Addisons.



Dave




David Bruyette, DVM, DACVIM
Medical Director
VCA West Los Angeles Animal Hospital
1900 South Sepulveda Blvd
Los Angeles, CA 90025
www.vcawla.com

David.Bruyette@vca.com

[labblab]

I respect Dr. Bruyette enormously, but I wouldn't feel comfortable waiting a full two months before retesting Lola. But personally, I would not retest as quickly as one week as long as she continues to behave happily and normally. This is because her cortisol level may continue to fluctuate for a while on the new dose and I would want to wait a bit longer to allow the level to further stabilize before retesting in order to get a more accurate assessment going forward. That's why I would allow at least two weeks.

The good news is that Dr. Bruyette does not seem to be concerned by Lola's lab abnormalities. As I said earlier, I really am not familiar with those particular blood chemistries. With Addison's, it is the balance between sodium and potassium that is the big worry. Apparently, Lola was within normal range on those two important values. I think chloride is related to sodium, but I don't know exactly how. I'm guessing that may be the value that that your own vet is wondering about, too. But it is only barely out of range right now, so apparently not an acute worry; perhaps instead a trend to keep an eye on.

So basically it seems as though Dr. Bruyette and your own vet are on the same page re: basic strategy -- reduce Lola's dose to 10 mg. The big question is just how soon to retest. If you are wanting to test sooner for your peace of mind, you can certainly do so.

Marianne

[Lola]

My vet suggested the 5mg twice daily instead of the once daily 10mg, because Lola seems to respond better to twice daily dose. She is ordering a box for me of the Vetoryl 5mg, until I receive it I will keep Lola on the morning 10mg. This will leave me with 2 unopened boxes of Vetoryl 10 mg. I will hold on to them for now until we figure out what dose she will stabilize on.
As for retesting, I think it's safe to retest about 10 days or so after we start the twice a day 5mg, what do you think?

Nadia

[Harley PoMMom]

As for retesting, I think it's safe to retest about 10 days or so after we start the twice a day 5mg, what do you think?

Nadia

Yep, waiting to test until Lola has been taking the 5 mg for 10-14 days is definitely what you want, that is the best way to gauge where her cortisol is on that dose regimen, unless, of course she would start to show adverse symptoms than one needs to be done sooner.

Hugs, Lori

[Lola]

A quick update on Lola's progress:
I started her on 5mg 2xday this morning. It took me a couple of days to get the new Vetoryl 5mg, I was doing the 10mg once a day. She seems to respond better to twice a day dosage.
She continues to behave normally, I haven't noticed any excess thirst or hunger which could indicate elevated cortisol, nor have I noticed any lethargy or weakness that could be indicative of very low cortisol either. So I guess we may be on the right track :)
She did have one loose stool yesterday, nothing that some Tylosin and a day of blend diet couldn't take care of. She had normal stool this morning, which makes this mama very happy :)
I will retest again in 10 days.

I hope everyone is having a great weekend

Nadia

[molly muffin]

That is great to hear. They usually do react pretty good to the split dose, as the levels stay more even throughout the day.

Let us know what the tests show.

[Lola]

Hello everyone,
I hope you all had a great thanksgiving.

I took Lola in today for her ACTH Stim Test and electrolytes. She has been on the lower 5mg twice a day dose for about 3 weeks now, and she has been really good at home.
Well, the electrolytes test came back right away, the Stim test results wont be in until tomorrow morning. The values are even more confusing than last time. I posted below the values from 11/10 test, and across from those, in red, the values from today:

November 10 test: Today's test:
TCO2 Bicarbonate 9 (normal 12-27) 23
Chloride 106 (normal 108-119) 102 (low)
Triglycerides 436 (normal 20-150) wont know until tomorrow
Anion Gap 32 (normal 11-26) wont know until tomorrow
BUN 29 (normal 9-31) 32 (high)

I guess these results looked at separate from the pre and post wont mean much, but I wanted to get your opinion on what you think may be causing these values to go in and out of range in such a short time. The TCO2 went up and is normal now, but on the other hand the chloride is very low when it was normal three weeks ago. same with the BUN that is now out of range.
I will post the rest of the tests results tomorrow as soon as I get them from the vet.

thank you all for your help

[molly muffin]

BUN can vary on many different things including whether she was a bit dehydrated or not when the test was done, or if she'd been eating a higher protein dog food, that sort of thing. So unless Creatinine is also out of range high, then I don't worry about that one too much.

I'm not sure what is going on with the others and hopefully the other test results will give you a and us a better picture.

Also, I'd suggest having a chat with the vet once the results are back and getting his/her thoughts on what might be going on.

[Lola]

Lola's ACTH Stim test results are in:

Pre 2.3
Post 3.4

These numbers are perfect, but they still don't give any clue as to why her Chloride level keeps going down. Could it be because she had a bad diarrhea on Saturday, 2 days before the test was performed?

I will retest the electrolytes in a month and Stim test in three months, we are keeping the Vetoryl at 5mg x2 day for now.

What do you guys think?

[lulusmom]

Hi Nadia and congratulations on the awesome stim test results! Did you get the latest triglyceride results? High triglycerides is caused by too much lipids (fat) in the blood and this can cause a certain degree of lipolysis in a blood specimen, which in turn can cause false highs and lows on some serum blood values. This could explain the low chloride levels but you really should ask your veterinarian as he will interpret any abnormalities in conjunction with other values. If he didn't express any concern with the low chloride, he's probably not worried about it. You could help my continuing education if you share anything you learn from your vet. :D

Glynda

[Lola]

Thank you Glynda,
You are right, the vet didn't seem to be too concerned about it even last time when the cortisol levels were off. She said the sodium was normal so she wasn't too concerned about the chloride.
I went and compared all Lola's blood work from two years ago, the chloride was normal when she was diagnosed, then went way up, then back to normal for a few months, then low along with the creatinine and the high sodium, them all normal again.... Until my head started spinning :)
I will retest the electrolytes again in 3 weeks. I am still thinking that the chloride was low this time because of the a cute diarrhea episode 2 days prior to test. She was depleted and dehydrated it seems.

I will keep you all updated

[molly muffin]

Just want to say Happy New Year to you and Lola. Hope she is still doing well and that everything remains stable.

[Lola]

Sharlene, Thank you so much for checking on us. Happy new year to you as well.

Lola has been doing great! She has never been better.
We had an ACTH Stim test as well as full blood work done yesterday. The vet called me this morning to tell me that her pre and post were perfect, but she was concerned with the rising triglycerides level. From a little over 400 three months ago to over 600 now.
I will get copies of the results and post them here, but wanted to see if anyone here has any diet suggestion on how to lower triglycerides, or if I should be testing for something else that may be causing it to rise.

Thank you all and god bless

[molly muffin]

Well usually low fat is what we say with schnauzers who are sure prone to high trigs too. Even treats need to be on the low fat end. Not sure if there is something they can give her to help bring it down or not.

[Lola]

Hello everyone,

As always, I didn't know where to turn for advice but to come here. You have been a tremendous help in this journey, dealing with the ups and downs of Cushing's effects on my poor little baby. Your advice is always appreciated and is taken above anyone else's.

Lola has been on Vetoryl 5mg twice daily and she has been doing fantastic. we did full blood work in November and again in February. There were no values that looked alarming and her behavior at home was fantastic.


we redid all the tests again yesterday and I almost dropped to the floor when I saw how much her ALT has increased (from 42 in feb to 512 now). She had an episode of vomiting once in April, that's about it. she is not exhibiting any signs of discomfort or nausea, eating and drinking well. I will attach the lab results once I find out how to do it. Her pre and post are perfect, the triglycerides went down, calcium normal, like I said the only thing that almost caused me a heart attack are the liver values.

I am freaking out right now thinking that her liver is deteriorating fast. The vet suggested that we do an abdominal ultrasound, which I'm doing next week. But could you please help me understand what may have caused the ALT to go up this fast, is it reversible with medication or not. What's the worst and best case scenarios I should be considering and getting ready for?

Again, your advice is so much appreciated in a way that I can't even put into words.

Thank you and god bless!

Nadia

[molly muffin]

I think the ultrasound will tell you more than anything else regarding whats going on with her liver. One thing to make sure they check is the gall bladder for sludge. That can affect the liver greatly and can even cause a blockage, so that is probably the first thing I'd want verified is that it is clear and okay.

The other is to check the liver itself, see if there are any nodules on it that might be growing.

These are the only things I can think of off the top of my head.

Let us know what the ultrasound shows.

[Harley PoMMom]

Hi Nadia,

Could you get copies of those test results, especially those ACTH stimulation tests, and post all values that are abnormal with the references ranges?

Yep, that is quite a jump in the ALT, however the levels of the other liver enzyme markers have to be looked at in conjunction with the high ALT. Some of those other liver markers are: gamma-glutamyltransferase (GGT), aspartate transaminase (AST), bilirubin and albumin.

Any kind of gut trouble can cause an elevation in the ALT, how has her tummy been acting lately? I believe an abdominal ultrasound is a really good next step. Is the vet performing the ultrasound, and if so, does he have an optimal machine?

A bile acid test is another option, this test will show if the liver is functioning properly.

Hugs, Lori

[Lola]

Thank you all so much.
I am having an ultrasound done on Monday at the IMS specialty hospital, I believe they have state if the art machines but I will ask anyway. I will ask her to look at the gallbladder as well and do a bike test.
Do you know how to upload a PDF file here? It has all the values side by side with values from two previous tests for comparison.


Thank you

[Harley PoMMom]

Unfortunately, members do not have permission to upload pdf files, however if you would just type in those abnormal values that would be great...as an example: ALT 150 U/L (5-50)

[Lola]

Thank you Lori.
Here are all the test results, normal and abnormal values so you can have a better picture. I will also add the values from February and November to keep things in perspective. The first readings are yesterday's.

Hematology:
RBC 7.42 M/uL (5.39- 8.7) Feb 7.31 Nov 7.26
Hematocrit 47.5% (38.3- 56.5) Feb 46.7 Nov 48.0
Hemoglobin 17.5 g/dL (13.4- 20.7) Feb 17.2 Nov 17.4
MVC 64fL (59- 76) Feb 64 Nov 66
MCH 23.6pg (21.9- 26.1) Feb 23.5 Nov 24.0
MCHC 36.8g/dL (32.6- 39.2) Feb 36.8 Nov 36.3
% Reticulocyte 1.3 % Feb 0.9 Nov 0.6
Reticulocyte 96K/uL (10- 110) Feb 66 Nov 44
WBC 9.5K/uL (4.9- 17.6) Feb 10.6 Nov 8.8
%Neutrophil 70.3% Feb 72.8 Nov 72.7
%Lymphocyte 19.7% Feb 16.1 Nov 17.0
%Monocyte 4.7% Feb 5.8 Nov 4.7
%Eosinophil 5.2% Feb 5.2 Nov 5.5
%Basophil 0.1% Feb 0.1 Nov 0.1
Neutrophil 6.679K/uL (2.94- 12.67) Feb 7.717 Nov 6.398
Lymphocyte 1.872K/uL (1.06- 4.95) Feb 1.707 Nov 1.496
Monocyte 0.447K/uL (0.13- 1.15) Feb 0.615 Nov 0.414
Eosinophil 0.494K/uL (0.07- 1.49) Feb 0.551 Nov 0.484
Basophil 0.01K/uL (0- 0.1) Feb 0.011 Nov 0.009
Platelet 293K/uL (143- 448) Feb 325 Nov 312

Chemistry:
Glucose 93mg/dL (63- 114) Feb 81 Nov 87
BUN 29mg/dL (9- 31) Feb 26 Nov 29
Creatinine 0.9mg/dL (0.5- 1.5) Feb 0.9 Nov 1.0
SDMA 7ug/dL (0- 14) Feb 11 Nov 3
BUN:Creatinine Ratio 32.2 Feb 28.9 Nov 29.0
Phosphorus 4.5mg/dL (2.5- 6.1) Feb 4.3 Nov 4.8
Calcium 11.3mg/dL (8.4- 11.8) Feb 11.3 Nov 11.2
Sodium 143mmol/L (142- 152) Feb 142 Nov 142
Potassium 4.4mmol/L (4.0- 5.4) Feb 4.6 Nov 4.8
Na:K Ratio 33 (28-37) Feb 31 Nov 30
Chloride 109mmol/L (108- 119) Feb 107 Nov 106
TCO2 17mmol/L (13- 27) Feb 19 Nov 9
Anion Gap 21mmol/L (11- 26) Feb 21 Nov 32
Total Protein 7.5g/dL (5.5- 7.5) Feb 7.0 Nov 7.0
Albumin 3.8g/dL (2.7- 3.9) Feb 4.0 Nov 3.8
Globulin 3.7g/dL (2.4- 4.0) Feb 3.0 Nov 3.2
Alb:Glob Ratio 1.0 (0.7- 1.5) Feb 1.3 Nov 1.2
ALT 512 U/L (18- 121) Feb 42 Nov 46
AST 81 U/L (16- 55) Feb 176 Nov 17
ALP 197 U/L (5- 160) Feb 145 Nov 182
GGT 13U/L (0- 13) Feb 6 Nov 4
Bilirubin- Total 0.1 mg/dL (0.0- 0.3) Feb 0.1 Nov 0.1
Bilirubin- unconjugated 0.0 mg/dL (0.0- 0.2) Feb 0.0 Nov 0.0
Bilirubin- conjugated 0.1 mg/dL (0.0- 0.1) Feb 0.1 Nov 0.1
Cholesterol 326 mg/dL (131- 345) Feb 328 Nov 325
Triglycerides 366 mg/dL (20- 150) Feb 665 Nov 436
Amylase 535 U/L (337- 1469) Feb 548 Nov 520
Lipase 309 U/L (138- 755) Feb 351 Nov 370
Creatine Kinase 152 U/L (10- 200) Feb 132 Nov 143
Hemolysis Index ++++ Feb +++ Nov ++
Lipema Index ++ Feb ++++ Nov +
Spec cPL 105 ug/L (0- 200) Feb 66 Nov 105

Urinalysis:
Collection Cystocentesis Feb Cystocentesis Nov Cystocentesis
Color Yellow Feb Yello Nov Yellow
Clarity Clear Feb Turbid Nov Cloudy
Specific Gravity 1.044 Feb 1.053 Nov 1.052
pH 6.5 Feb 8.0 Nov 7.0
Protein Negative Feb Negative Nov Negative
Glucose Negative Feb Negative Nov Negative
Ketones Negative Feb Negative Nov Negative
Blood/Hemoglobin Negative Feb Negative Nov Negative
Bilirubin Negative Feb Negative Nov Negative
Urobilinogen Norma; Feb Normal Nov Normal
White blood cells 0-2 HPF (0- 5) Feb 0-2 Nov 0-2
Red blood cells 0-2 HPF (0- 5) Feb 0-2 Nov 0-2
Bacteria None seen Feb None seen Nov None seen
Epithelial cells Rare (0-1)HPF Feb 1+(1-2) Nov 1+(1-2)
Mucus None seen Feb None seen Nov None seen
Casts None seen Feb None seen Nov None seen
Crystals None seen Feb None seen Nov None seen
Other: Amorphous debris present

Endocrinology:
ACTH Pre 2.6 ug/dL Feb 2.6 Nov 2.3
ACTH Post 4.0 ug/dL Feb 3.5 Nov 3.4
Total T4 3.5 ug/dL Feb 2.9


I hope this sheds some light on the whole picture. Any advice is always very much appreciated.


Thank you all so much and god bless


Nadia

[barbara1]

This forum is so wonderful. I recently joined and have been comforted by everyone.
I took my Bella to an internal medical vet that specialized in ultra sound. I researched it on the net. I don't know where you live but I found a vet hospital that was an affiliate of penn university here is NJ. The ultra sound confirmed cushings disease in my baby girl. I was in denial about her having the disease due to the false negative, positive results. I personally feel this is the best route to confirm this disease as you can see the tumors personally.
Everyone is right about starting on the lowest dosage you can. I also switched her to a diet of brown rice and boiled chicken as her stomach is sensitive and someone on this forum suggested giving the pill with a piece of cheese which I do.
Keep in touch with this forum. They will help you mentally get through this and you will realize you are never alone.

[Harley PoMMom]

Her ACTH stimulation tes results are perfect!!! And I see that her albumin and bilirubin are normal and no billirubin was found in the urine, which is another good thing. And now that I am seeing those elevations in her liver enzyme levels, I understand how worried you must be.

As Sharlene mentioned, bile duct obstruction or other causes of cholestasis may increase ALT and AST so having that ultrasound performed is definitely the next move I would take. If no cholestasis is found from the ultrasound the bile acid test would be my next step (cholestasis elevates bile acids so it would be pointless to have one performed).

Hugs, Lori

[Lola]

Thank you so much Lori for taking time to review those values.
So what you're saying is that it looks more like gallbladder issues rather than liver damage?
I am having an US done on Monday and will bring up all these hypothesis with the IMS.

Nadia

[judymaggie]

Nadia: The bile acid test measures how well the liver is functioning. Here is a website that provides a good explanation of the test and how it is performed:

http://www.vcahospitals.com/main/pet-health-information/article/animal-health/serum-bile-acids/122

[Lola]

Thank you Judy for the link, very informative.
My head is spinning with questions. Lola's AST went from 17 in November to 176 in February, that's ten time higher, then down by half in May! While that went down, the ALT spiked ten time higher within 3 months. The GGT, even though it's still within normal range, did more than double since February, and it's at the edge of becoming elevated. All that is very confusing to me and I have a million questions for the IMS on Monday.


Nadia

[judymaggie]

Nadia: Start writing out your questions now and, over the weekend, add as think of other things. Then make sure all your questions are answered before the end of your appointment on Monday. My vet just chuckles now at my lists but it does eliminate a lot of frustration on my part.

Enjoy your weekend with Lola -- give her a hug from us!

[Lola]

Thank you Judy, you're very sweet.
I too used to live in Riverview before I moved to California a few years ago :)
Enjoy your weekend


Nadia

[molly muffin]

Was anything else going on with Lola during the time her liver functions was going up and down?

Even supplements that might have been different?

[Lola]

No, not really. she has been great at home, no symptoms whatsoever. she did have an episode mid April where she vomited a few times one day. I gave her one dose of Cerenia and that took care of it. Other than that, I haven't changed anything: same food, same supplements, same medications...

I just came back from an IMS visit with Lola. We had an abdominal ultrasound done and this is the doctor's report:

"Lola's ultrasound was normal other than mild right adrenal enlargement and sensitivity to ultrasound pressure on right side. The pancreas on that side was visible but not abnormal per se.

we discussed findings and potential next steps.

I recommend recheck liver enzymes and pancreatic lipase 2 weeks from the last visit on 5/24/16.

if liver enzymes remain mildly elevated, options will be liver aspirate and trial therapy with Actigall and Clavamox.

if enzymes increase substantially, a liver biopsy may be recommended.

if enzymes are normal, then continued periodic monitoring will be sufficient."

That being said, the doctor and I had a very lengthy discussion in the exam room. she went over every organ image and answered all my questions. the liver was normal, gallbladder, spleen, adrenals..all were normal. The pancreas was very visible but not swollen or inflamed. the blood work confirmed that pancreatitis was negative, she recommended I switch Lola to a lower fat content food just to be on the safe side. Lola is already on Wellness Core Grain Free Reduced Fat currently, so I need to start researching a lower fat food.
She feels that the little enlargement of the right adrenal is not alarming as this is a normal side effect for dogs undergoing treatment with Vetoryl.
She is very confident that the liver enzymes may be normal next time, (ALT especially) because if you look at the blood work results I posted last week, the Hemolysis Index was ++++ and that affects the liver values. This is the footnote on Lola's blood work regarding that index: "Index of ++++ may increase AST and CPK by 25-50%, and decrease ALP by >50%, decrease Total and Direct Bilirubin values 25-50%, and decrease SDMA by 10-25%."

What do you all think of the IMS plan so far? Have any of you had any experience with the medications she suggested?

Thank you all so much

[Lola]

I was hoping some of the members would have looked at Lola's report card from the IMS and give their opinion.

[molly muffin]

I haven't used either of the drugs the vet mentioned but I'm sure others have used Clavamox. I don't recall any particularly issues surrounding it, but like I mentioned I haven't used it personally.

The ultrasound showing everything to be normal seems to suggest that the vet may be right that this is something in relation to the Hemolysis Index being high. This might have been caused by the sample itself and therefore the liver enzymes aren't accurate (abnormally high) because of it. So it seems that is what the vet is thinking.
In most cases they usually do a redraw and test again. (the 2 weeks test again that the vet mentioned)

I wouldn't think the liver would look so normal if there was a chronic liver problem.

[judymaggie]

Nadia--my Maggie (first Cush pup now at the bridge) was on Actigall (more commonly known as ursodiol) for gallbladder and liver disease. She tolerated it without problems. With both the liver and gallbladder looking normal on Lola's ultrasound it doesn't seem like she would need to be on it. Both Maggie and Abbie have taken Clavamox many times -- usually for UTIs, bladder infections, etc.

[lulusmom]

Hi Nadia. I think the IMS' plan sounds like a very good one considering everything you shared with us. Hopefully you felt some relief with the results of the ab ultrasound. Ya know, lLiver enzymes can spike over night and drop almost as quickly so it is quite possible that the next recheck will show some very good improvement. You just have to be patient which I know is not always easy. I do remember doing the hurry up and wait thing with both of my cushdogs on more than a few occasions. It's enough to drive you nuts, which may be why some people still whisper behind my back. :D:p:D

Hugs,
Glynda

[Lola]

Thank you all so much for the reassurance that I very much needed :)
I am almost certain that the next blood test will be better, Lola is still doing so great at home.
I started transitioning her to Instinct Raw Boost senior chicken meal, it seems to have a little less fat that the Wellness Core Reduced Fat. She wasn't too excited about it but is eating it anyway :)

I will keep you updated as soon as I get more news


Thank you

[Lola]

Hello everyone,
I hope everyone had a great Thanksgiving and are getting ready for the holidays.
I know I have been away for a while. Life has been hectic. I'm having some marriage issues that have taken what's left of my sanity. So I apologize if I'm not participating in this forum as often as I used to.

Lola has been doing good as far as her Cushing's control. Her latest blood results were fine, except for slightly elevated blood pressure.
But on the other hand, her arthritis has gotten worse. Her left knee is almost all arthritis tissue now. I took her for a short walk on the beach on thanksgiving morning and I didn't realize that I would be unleashing a storm. She was lame the rest of the day that day. I took her to the vet on Friday at 7am, did X-rays, vet said Arthritis has gotten really bad on the left knee. She has been on Dasuquin, and monthly Adequan injections for three years now, but those seem to not be helping any longer, and I need to do something else about her arthritis.
I discussed the few options available with the vet and she thinks that Lola would not be a good candidate for hip replacement surgery because of her Cushing's, so we need to look into more conservative ways.
So far, we decided to increase the Adequan injections to bi weekly instead of monthly and give her a dose of tramadol as needed.

My next steps are really all blurry inside my head.
- should I have her seen by an orthopedic surgeon anyway? It seems odd to me that the onset would be literally overnight. She was perfectly fine before that walk on the beach
-I'm also thinking of seeing a holistic vet to discus herbal supplements and maybe acupuncture
- I ordered organic turmeric and coconut oil to start her on golden paste? I'm not sure what dose to start her at, or if that would even help with Arthritis pain
- I even considered consulting with a stem cell surgeon to discuss that option as well.
Lola just turned ten this past Thursday. I feel so blessed to still have her around. When I see her limp, a piece of my heart breaks with every step she takes in pain.


Thank you all for any help you can provide and God bless


Nadia and sweet Lola

[molly muffin]

Hi Nadia,

Oh poor Lola, that sounds so painful. I think hope the bi-weekly injections help.
Maybe a consult with the stim cell surgeon would be beneficial. I know someone who used it for his dog, but I can't remember what issue it was. I remember they had fairly good results.
Also I was thinking someone had mentioned a new arthritis medication for dogs, coming soon.
Holistic is always as option as you said too, as others have had decent results using acupuncture.
I really don't know which would work best. Hopefully it is just a flare up, but no more beach walks, as I think sand would be difficult if she is having pain in that leg.
I'm sorry to hear that life has been such a jumble for you and I hope that sorts out in a way that is positive for you and Lola.

[Lola]

Thank you Sharlene.
I read somewhere that stem cell therapy causes dogs to get cancer, so I'm keeping that option as my last resort. Ideally, I would go for the hip replacement surgery had Lola been Cushing's free.
So right now, I'm looking into ways to reduce the inflammation and pain without putting her in harm's way.

Thanks again

Nadia and sweet Lola

[Harley PoMMom]

Hi Nadia,

What were the results of Lola's last ACTH stim test? Another option could be to let her cortisol rise a bit higher to help with the arthritic pain and inflammation.

[Lola]

I had Lola seen by an orthopedic surgeon, the same one that saw her before for her torn ACLs. He doesn't think that her arthritis has gotten worse, he thinks that he body's tolerance of the pain has gotten down, that's what's causing her to limp more now, and the problem is in her knees not her hips like the regular vet suggested. He put her on Gabapentin for two weeks. Gabapentin targets the nervous system to increase the body's pain tolerance. He also thinks that she will benefit form acupuncture and maybe some natural supplements such as golden paste.
He speaks very highly of this new drug that's coming out in January and I could see it in his eyes that he really is passionate about pets wellbeing and believes in targeting the issue rather than causing other things to break like it is the case with Metacam and other anti-inflammatory drugs available now. The new drug is called Galliprant (I edited to include link to webpage below), and it targets the inflammation directly, sparing the liver and kidneys. he will write me a prescription as soon as it's available in the US. He also told me about this new drug that was only available for cats and will be available for dogs soon (it is already available in Canada). it's called Onsior. that's another anti inflammatory drug with no harmful side effects.
I have an appointment with a holistic vet this Thursday to discuss acupuncture treatment. I will keep you all updated on that later.

http://www.aratana.com/therapeutics/osteoarthritis-pain/



Thank you all and god bless

[molly muffin]

this sounds very positive. Hopefully both drugs will be available for dogs world wide soon.

[Lola]

What is an average dosage for the gabapentin without causing kidney damage?
The doctor prescribed two weeks of 75 to 100mg twice daily, does this sound about right? I never used this drug before so any info would help


Thank you

[lulusmom]

Nadia, I have never used Gabapentin but I just researched the dosing for pain control and the range is from 1.5 to 5 mg per pound (3 to 10 mg/kg) every 24 hours. If Lola weighs 15 pounds, that range would be 22.5 mg to 75 mg. I could not find anything that says this drug actually causes kidney dysfunction but there is a warning that it should be used with caution in dogs with decreased liver and kidney function. If this is a concern, I highly recommend that you discuss it with the prescribing vet.

Glynda

[Squirt's Mom]

I take Gabapentin, a rather large dose in fact, and have for years. With one functioning kidney my kidney values have remained constant thru the years so I don't know about it causing kidney problems. My Sophie, 18 lbs, also takes it and she gets 125mg 2x a day PRN (as needed). Hope that helps!

Hugs,
Leslie and the gang

[Lola]

Thank you all for your input.
Lola is 18lbs and so far she took two doses of 75mg each.
The prescribing doctor actually consulted with Lola's IMS onsite before authorizing the drug, so he had the full picture in mind as far as all that's going on with her. He also looked at the most recent blood work as well.
He prescribed 50mg pills and asked me to start with one and a half twice daily, preferably start the first doe at bed time because it will make her sleepy. I started last night, this morning Lola was fine and completely happy, I just gave her the second dose about an hour ago, she's used to taking afternoon naps anyway so this would help. He said the sleepiness should go away in about 6 days, and I can go up to 2 pills twice daily if need be.
Lola has not limped in two days, she is doing much better already so I don't even think that I will finish the entire course, I may stop it in a couple days. Hopefully that wont cause any issues. We're also starting acupuncture tomorrow so that should help too.

Nadia

[labblab]

Hi Nadia,

That's wonderful that the gabapentin seems to be helping so much. That being the case, I'm not sure that you would want to discontinue it before going through the complete two-week course. If you do stop so quickly, you may quickly find yourself back at Square One. With many inflammatory/neurological/pain issues, you need to have some extended treatment in order to allow the underlying condition to stabilize or heal. As long as Nadia seems to tolerate the medication with no problems, I'd be inclined to follow the vet's recommendation as far as completing the full two weeks -- or at least asking him first if he thinks it's OK for you to stop after only a few doses.

Marianne

[Lola]

Thank you Marianne
The doctor said that this drug is very mild on the kidneys and liver so I think I may jus continue the full course as long as Lola is not showing any signs of possible side effects.


Nadia